1. Colorectal Cancer Update for Healthcare Providers May 2013 Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Cigarette Restitution Fund Program Center for Cancer Prevention and Control

2. Prevention and Health Promotion Administration May 2013 2 CRC Incidence, Mortality, and Survival in the U.S.

3. Prevention and Health Promotion Administration May 2013 3 Colorectal Cancer Third most commonly diagnosed cancer in Maryland among both men and women Second leading cause of cancer-related mortality Incidence and mortality have been decreasing in recent years

4. Prevention and Health Promotion Administration May 2013 4 Colorectal Cancer Incidence and Mortality Rates by Year of Diagnosis or Death, Maryland, 2002-2008 Maryland Cancer Registry (incidence rates) NCHS Compressed Mortality File in CDC WONDER (mortality rates)

5. Prevention and Health Promotion Administration May 2013 5 Source: SEER 9 areas. SEER Program, National Cancer Institute. 5-year CRC survival has improved over the past 30 years in the U.S. Colorectal Cancer

6. Prevention and Health Promotion Administration May 2013 6 CRC Screening

7. Prevention and Health Promotion Administration May 2013 7 Colorectal Cancer Screening Status of People Age 50 Years and Older Maryland Cancer Surveys and BRFSS, 2002-2010 Maryland Cancer Survey, 2002-2008 BRFSS, 2010

8. Prevention and Health Promotion Administration May 2013 8 80% of people 50+ in Maryland reported having a provider recommend 80% of people 50+ in Maryland reported having a provider recommend endoscopy….. of those, 88% got screened Percent Screened with Endoscopy Maryland Cancer Survey, 2008 Provider Recommendation is KEY to Screening Of the 20% who did NOT report a provider recommendation….only 24% got screened

9. Prevention and Health Promotion Administration May 2013 9 Colorectal Cancer Screening with colonoscopy or sigmoidoscopy? (50+ years) Never screened with colonoscopy or sigmoidoscopy 25% Ever screened with colonoscopy or Sigmoidoscopy 75% Maryland Cancer Survey, 2008

10. Prevention and Health Promotion Administration May 2013 10 Colorectal Cancer Screening with colonoscopy or sigmoidoscopy? (50+ years) Never screened with colonoscopy or sigmoidoscopy 25% Ever screened with colonoscopy or Sigmoidoscopy 75% 85% have been to doctor for “routine checkup” in past 2 years in past 2 years Only 15% have NOT had checkup Maryland Cancer Survey, 2008

11. Prevention and Health Promotion Administration May 2013 11 Patient: Family and personal history Past screening Symptoms Primary Doctor: Referral Pathologist: Pathology report Case Management and Communication Colonoscopist: Risk history Medication changes Prep instructions Post colonoscopy instructions Colonoscopy report Findings Recommendations

12. Prevention and Health Promotion Administration May 2013 12 Who needs screening?

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15. Prevention and Health Promotion Administration May 2013 15 Colorectal Cancer Cases by Risk History Sporadic (average risk) (65%–85%) Family history (10%–30%) Hereditary nonpolyposis colorectal cancer (HNPCC, 2-3%) Familial adenomatous polyposis (FAP) (<1%) Rare syndromes (<0.1%) http://www.cancer.gov/cancertopics/pdq/genetics/colorectal/HealthProfessional

16. Prevention and Health Promotion Administration May 2013 16 Risk of CRC GroupApprox. lifetime risk of CRC General Population5-6% One first degree relative (FDR) with CRC2--3-fold increase over general population Two FDRs with CRC3--4-fold increase FDR with CRC diagnosed < 503--4-fold increase One second or third degree relativeAbout 1.5-fold increase Two second degree relativesAbout 2--3-fold increase Inflammatory Bowel Disease (ulcerative colitis and Crohn’s colitis) 7-10% have CRC after having ulcerative colitis for 20 years; then ~1%/year Familial adenomatous polyposis (FAP) Hereditary non-polyposis colorectal cancer (HNPCC) ~100% ~80+% Burt RW. Gastroenterology 2000;119:837-53 Winawer S, et al. Gastroenterology 2003;124:544-560

17. Prevention and Health Promotion Administration May 2013 17 Average Risk Increased Risk Colonoscopy, every 10 years or FOBT or FIT annually if refuse endoscopy or Flexible sigmoidoscopy, every 5 years with a high sensitivity fecal occult blood test* (FOBT), every 3 years Colonoscopy (interval for repeat depends on risk, history, and prior colonoscopy results) Maryland Screening Recommendations: Medical Advisory Committee on CRC * Hemoccult SENSA or fecal immunochemical test (FIT)

18. Prevention and Health Promotion Administration May 2013 18 Risk CategoryAge to Begin Screening Average riskAge 50 years Increased risk Family History Colorectal cancer or adenomatous polyp(s)* in an FDR age <60, or in 2 or more FDRs at any age * Especially if advanced adenomas: > 1 cm; villous histology; or high grade dysplasia Age 40 years, or 10 years before the youngest case in the immediate family, whichever is earlier Genetic syndrome: Familial adenomatous polyposis (FAP) Hereditary non-polyposis colorectal cancer (HNPCC) Age 10 to 12 years Age 20 to 25 years, or 10 years before the youngest case in the immediate family Inflammatory bowel diseaseCancer risk begins to be significant 8 years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left- sided colitis Rex DK, et al. Am J Gastroenterol 2009:104;739-750 American Cancer Society, 2012 http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancer EarlyDetection/colorectal-cancer-early-detection-acs-recommendations Age to Begin Screening by Risk Category

19. Prevention and Health Promotion Administration May 2013 19 Guidelines Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the U.S. Multi-Society Task Force on CRC, and the American College of Radiology CA Cancer J Clin 58: 130-160 (May 2008)

20. Prevention and Health Promotion Administration May 2013 20 Tests that Find Both Polyps and Cancer  Flexible sigmoidoscopy every 5 years  Colonoscopy every 10 years  Double contrast barium enema every 5 years  CT colonography (virtual colonoscopy) every 5 years Guidelines, American Cancer Society, June 2012 http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRect umCancerEarlyDetection/colorectal-cancer-early-detection-screening-tests-used

21. Prevention and Health Promotion Administration May 2013 21 Tests that Primarily Find Cancer  High sensitivity FOBT every year  Hemoccult SENSA or fecal immunochemical test (FIT)  Stool DNA test (unclear how often this is needed, not currently available commercially is U.S.) Guidelines, American Cancer Society, 2012 http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer- detection-recommendations United States Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/coloartzaub.htm#results

22. Prevention and Health Promotion Administration May 2013 22 CRC Screening Guidelines American Cancer Society, June 2012 Beginning at age 50, men and women at average risk for CRC should use one of the screening tests. The tests that are designed to find both early cancer and polyps are preferred if these tests are available to the patient and the patient is willing to have one of these more invasive tests. Talk to your doctor about which test is best for you.

23. Prevention and Health Promotion Administration May 2013 23 CRC Screening under the Cigarette Restitution Fund Program (CRFP) in Maryland CRC Screening under the Cigarette Restitution Fund Program (CRFP) in Maryland

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28. Prevention and Health Promotion Administration May 2013 28 Summary of Cigarette Restitution Fund Colorectal Cancer Screening in Maryland As of December 31, 2012: 23,203 People have had one or more screening procedures ______________________________________ FOBTs (all income levels) 8,356FOBTs (all income levels) Sigmoidoscopies 181Sigmoidoscopies Colonoscopies 21,355Colonoscopies DHMH, CCPC, Client Database, C-CoPD, as of 2/25/2013

29. Prevention and Health Promotion Administration May 2013 29 Summary of Cigarette Restitution Fund Colorectal Cancer Screening ________ County, Maryland 2000-20XX: XX Individuals screened for CRC by one or more method + by one or more method + ____________________________________________________________ XX FOBTs* XX Colonoscopies* ____________________________________________________________ X Cancers* X Cancers* X High grade dysplasia* X High grade dysplasia* XX Adenoma(s)* XX Adenoma(s)* DHMH, CCPC, Client Database, C-CoPD, as of xx/xx/xxxx DHMH, CCPC, Client Database, C-CoP, as of xx/xx/xxxx Obtain numbers for your jurisdiction from the Client Database, C-CoPD and C-CoP reports, or call Lorraine Underwood 410-767-0791

30. Prevention and Health Promotion Administration May 2013 30 Gender of 23,173 Screened* for CRC Maryland, 2000-December 2012 *Of clients with known gender screened with one or more of the following: FOBT, flexible sigmoidoscopy, colonoscopy, imaging Women 15,586 (67%) Men 7,587 (33%) DHMH, CCPC, Client Database, C-CoPD, as of 2/26/2013

31. Prevention and Health Promotion Administration May 2013 31 Minority Status of 23,203 New People Screened* for CRC, Maryland, 2000-December 2012 *Of clients screened with one or more of the following: FOBT, flexible sigmoidoscopy, colonoscopy, imaging Non-minority or Unknown 11,110 (48%) Minority 12,093 (52%) DHMH, CCPC, Client Database, C-CoPD, as of 2/26/2013

32. Prevention and Health Promotion Administration May 2013 32 Results* of 21,356 Colonoscopies Maryland Cigarette Restitution Fund Program Maryland, 2000-December 2012 * Most “advanced” finding on colonoscopy DHMH, CCPC, Client Database, C-CoP, as of 2/27/2013

33. Prevention and Health Promotion Administration May 2013 33 Recommended screening after initial screening-- rescreening or surveillance colonoscopy “Recall Interval”

34. Prevention and Health Promotion Administration May 2013 34 then what After first colonoscopy, then what? Interval between colonoscopies will depend on: – findings on last colonoscopy, – risk history, and – symptoms

35. Prevention and Health Promotion Administration May 2013 35 For the recommended recall intervals, please see: DHMH Colorectal Cancer Minimal Elements http://phpa.dhmh.maryland.gov/cancer/Shared%20Documents/ccpc13- 24--att_CRCMinimalElements2013[1].pdf (or http://phpa.dhmh.maryland.gov/cancer/ under Resources)

36. Prevention and Health Promotion Administration May 2013 36 Guidelines for Recall Intervals Following Colonoscopy Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 2012;143:844–857 Rex DK, Ahnen DJ, Baron JA, Batts KP, Burke CA, et al. Serrated lesions of the colorectum: Review and recommendations from an expert panel. Am J Gastroenterol. 2012:109;1315-29.

37. Prevention and Health Promotion Administration May 2013 37 Keys to the right recall 1. Colonoscopy Report 2. Pathology Report 3. Recommendation based on guidelines 4. Communication

38. Prevention and Health Promotion Administration [Date] 38 Standards for Colonoscopy Reports— CO-RADS* Colonoscopy report should include: Date and Time - Procedure Patient description Risk factors ASA class Indications Consent signed Sedation Colonoscope Bowel prep adequacy Whether cecum reached Colonoscopy withdrawal time Findings Specimen(s) to path lab Impression Complications Pathology Recommendations Follow-up plan/Recall Other *Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable, Lieberman et al., Gastrointestinal Endoscopy 2007; 65: 757-766

39. Prevention and Health Promotion Administration May 2013 39 Adequacy of First Colonoscopy Among 16,813* First Cycle Colonoscopies Maryland, 2000-December 2012 *16,813 of the 17,915 first colonoscopies had information on “adequacy” of the col in CRFP. DHMH, CCPC, Client Database, Data Download, 2/27/2013

40. Prevention and Health Promotion Administration May 2013 40 Reporting on Colonoscopy Findings: – Number of masses, polyps, other lesions (try to give actual or estimated number rather than “several” or “multiple”) – Findings:for EACH mass/polyp/lesion location size description tattoo biopsy(ies) taken method of each biopsy whether lesion completely removed or not whether there was piecemeal removal whether specimens retrieved whether saline lift used number of specimens sent to pathology

41. Prevention and Health Promotion Administration May 2013 41 How will your patients be reminded about their next colonoscopy?

42. Prevention and Health Promotion Administration May 2013 42 Patient: Family and personal history Past screening Symptoms Primary Doctor: Referral Pathologist: Pathology report Case Management and Communication Colonoscopist: Risk history Medication changes Prep instructions Post colonoscopy instructions Colonoscopy report Findings Recommendations

43. Prevention and Health Promotion Administration May 2013 43 Acknowledgements Funding from the Maryland Cigarette Restitution Fund (CRF) Staff and partners of Local Public Health Department Programs in MD and their contracted providers DHMH Center for Cancer Prevention and Control (CCPC) Database and Quality assurance Surveillance and Evaluation Unit including - University of Maryland at Baltimore - Ciber, Inc. CCPC CRF Programs Unit Maryland Cancer Registry Minority Outreach Technical Assistance Partners

44. http://phpa.dhmh.maryland.gov PREVENTION AND HEALTH PROMOTION ADMINISTRATION